7 Day

Consultant-Present Care:

encouraging implementation

Dr Chris Roseveare

Co-Chair AoMRC 7 day Project sub-committee

The weekend challenge…

• Higher case-mix adjusted mortality

– new admissions and in-patients

• Greater illness severity amongst weekend

admissions

• Fewer consultants in hospital

‘..I am relieved on Monday that

nothing catastrophic has

happened over the weekend’

7 day working: what do we mean?

• ‘Emergency’ Care:

• ‘Elective’ Care:

• ‘Urgent’ Care:

• Must Do’s

• Could Do’s

• Should Do’s

‘A consultant

presence should be

maintained on the

AMU for a minimum

of 12 hours per day,

7 days per week’

The Benefits of Consultant-Delivered Care

•Rapid and appropriate decision making

•Improved safety, fewer errors

•Improved outcomes

•More efficient use of resources

•GP's access to the opinion of a fully trained doctor

•Patient expectation of access to appropriate and skilled

clinicians and information

•Benefits for the supervised training of junior doctors.

The Benefits of Consultant-Delivered Care

‘the benefits of consultant-delivered care should be available to

all patients throughout the week …. work should be undertaken

by clinicians and employers to map out the staffing

requirements and service implications of implementing a

consultant-delivered service throughout the week’

The Benefits of Consultant-Delivered Care

‘the benefits of consultant-delivered care should be available to

all patients throughout the week …. work should be undertaken

by clinicians and employers to map out the staffing

requirements and service implications of implementing a

consultant-delivered service throughout the week’

• ‘No point in me being here if I can’t get the tests

done which enable me to make a difference’

• ‘No point me doing that test unless someone is

going to act on the result’

• ‘Can’t send the patient home at the weekend

because primary care isn’t working’

WE’RE ALL IN IT TOGETHER…

AoMRC 7 DAY WORKING PROJECT

•Steering committee formed April 2012•Subgroup to define remit of project

• Call for information from Royal Colleges• Literature review• Key ‘standards’ to be defined

REMIT OF PROJECT

•Focus on Patient Safety

•‘In-patient wards’• Not just ‘acute’ areas

•7-days - not just weekends

Standard 1

Hospital inpatients should be reviewed by

an on-site consultant at least once every

24 hours, seven days a week, unless it has

been determined that this would not affect

the patient’s care pathway.

Standard 2

Consultant-supervised interventions and investigations

along with reports should be provided seven days a

week if the results will change the outcome or status of

the patient’s care pathway before the next ‘normal’

working day.

Standard 3

Support services both in hospitals and in the

primary care setting in the community should

be available seven days a week to ensure that

the next steps in the patient’s care pathway, as

determined by the daily consultant review, can

be taken.

‘While the RCP accepts this as an aspirational standard

for all physicians, we believe that this will require service

redesign and may have resource implications to make this

a comprehensive reality’

Sir Richard Thompson

President , RCPL

• Challenges for implementation

– contracts / job plans

– specialism vs generalism

– continuity of care

– costs

How many consultants?

Approximate

number of beds on

AMU

Number of

admissions per

24hrs

Approx. Number

of patient

contacts 8am-

8pm

No. consultant

equivalents req’d on

the AMU 8am-8pm

<30 ≤ 25 ≤55 1 - 1.5

30-50 25-44 55-89 1.5 – 2

51-70 45-60 90-135 2 – 3

>70 >60 >135 >3

Source: RCPL Acute Care Toolkit 4

October 2012

‘Downstream’ Staffing implications…..

100 Medical / elderly care beds

60% requiring daily consultant review

15 mins per patient

= 15hrs consultant time per day

= 10PAs per weekend

‘The method by which a consultant-led

review takes place need not be constrained

to formal, physical bed-side ward

rounds by a consultant’

‘Phased’ implementation of Standard 2:

‘…giving higher priority to those that might

lead to a more immediate change in outcome’

Other appropriate methods of consultant-led review could include:

• Ward round undertaken by a doctor in training

or SAS doctor, followed by a discussion of all,

and review of selected patients by the consultant

• A multi-disciplinary team ‘board-based’ round.’

Next Steps: PART 2

•More detailed summary of implications for each speciality / college

• Resource implications• Staffing requirements• Support services

Terms of reference being developed

Aiming to report by end of 2013

So will it make a difference?

‘No Brainer……………….

…………or Expensive Experiment?’

What is the evidence…..?

Stepping Up: A Phased Evaluation of the

Impact of High-Intensity Specialist-Led Acute Care (HiSLAC)

of Emergency Medical Admissions

to NHS Hospitals (Commissioned call 12/128)

5 year study in 3 phases

Proposed by Prof Julian Bion, University of Birmingham